What we already know about this topic

Superficial thrombophlebitis (ST) is a common condition, with a prevalence of about 0,64% per year (1). In the last decades, many different therapeutic strategies have been proposed but only recently data from large trials are available for decision making. Main focuses of the treatment should be the prevention of evolution to deep vein thrombosis (DVT) and pulmonary embolism (PE) and the reduction of pain, that is frequently associated.

The review we will summarize evaluates the efficacy and safety of the topical, medical and surgical treatments for ST tested in randomized clinical trials.

The Cochrane review (2)

Title: Treatment for superficial thrombophlebitis of the leg.

Authors: Di Nisio M, Wichers IM, Middeldorp S.

Bibliographic citation: Cochrane Database Syst Rev 2018; 2:CD004982.

Objective: to assess the efficacy and safety of topical, medical, and surgical treatments for ST of the leg in improving local symptoms and decreasing thromboembolic complications.

Included studies: randomized controlled trials evaluating topical, medical and surgical treatments for ST of the legs.

Comment and conclusions

The results of this systematic review confirm the recommendations of the latest guidelines on the subject. Both the American College of Chest Physicians and British Committee for Standards in Haematology (BCSH) documents suggest anti-coagulation for ST of the legs longer than 5 cm with fondaparinux o prophylactic dose LMWH (3,4).

In this systematic review, fondaparinux (2,5 mg daily for 45 days) appeared to be efficacious in reducing the incidence of MTVE during the follow up (RR 0,15 [95% C.I. 0,04 – 0,5]), the extension and the recurrence of SVT based on data from the CALISTO trial; quality of evidence was downgraded to moderate because of low number of events.

While for the strategy based on therapeutic dose of LMWH no clinical efficacy was demonstrated, when prophylactic dose was used a reduced incidence of extension or recurrence of ST was reported. In both cases, no major bleedings were recorded, probably because the sample size was not large enough to detect them. Consequently, the ACCP guidelines suggest the use of fondaparinux over prophylactic dose LMWH for treatment of SVT (3).

No conclusions can be drawn for NSAID, topical or surgical options due the small sample dimensions of the published trials and their low methodological quality.

For the whole of the included studies there is a high risk of bias; for this reason, quality of evidence is defined as low for most of interventions. Statistical analyses for publication bias were not performed because most studies did not evaluate the same treatment comparisons on the same study outcomes.

Anti-coagulation is now fully considered part of the treatment of SVT and the results of this meta-analysis, although based upon the data of the unique original trials, confirm this approach. In the future, it would be interesting to understand which anti-coagulation regimen is more useful and safe with a direct comparison of fondaparinux with LMWH.

Note:

SVT which extends to within 3 cm of the sapheno-femoral junction should be treated like DVT because the risks of progression are similar.